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Meta-Analysis of integrated therapeutic methods in noninvasive lower back pain

Publikacja / Publication therapy (LBP): the role of interdisciplinary functional diagnostics,
Bitenc-Jasiejko Aleksandra, Konior Krzysztof, Lietz-Kijak Danuta
DOI wersji wydawcy / Published version DOI http://dx.doi.org/10.1155/2020/3967414
Adres publikacji w Repozytorium URL / Publication address in Repository https://ppm.edu.pl/info/article/PUM0a7c35508f3246a18d8ee1c116a305d5/
Data opublikowania w Repozytorium / Deposited in Repository on 16 mar 2021
Rodzaj licencji / Type of licence Attribution (CC BY 4.0)
Bitenc-Jasiejko Aleksandra, Konior Krzysztof, Lietz-Kijak Danuta: Meta-
Analysis of integrated therapeutic methods in noninvasive lower back pain
Cytuj tę wersję / Cite this version therapy (LBP): the role of interdisciplinary functional diagnostics, Pain Research
& Management, vol. 2020, 2020, Article number: 3967414, pp. 17,
DOI:10.1155/2020/3967414
 Hindawi
Pain Research and Management
Volume 2020, Article ID 3967414, 17 pages
https://doi.org/10.1155/2020/3967414

Review Article
Meta-Analysis of Integrated Therapeutic Methods in Noninvasive
Lower Back Pain Therapy (LBP): The Role of Interdisciplinary
Functional Diagnostics

Aleksandra Bitenc-Jasiejko ,1 Krzysztof Konior,2 and Danuta Lietz-Kijak 1

1
Department of Propedeutics, Physical Diagnostics and Dental Physiotherapy, Pomeranian Medical University in Szczecin,
Szczecin, Poland
2
Medical Center in Nowogard, Nowogard, Poland
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Correspondence should be addressed to Danuta Lietz-Kijak; [email protected]

Received 13 December 2019; Accepted 7 February 2020; Published 20 March 2020

Guest Editor: Ji Tu

Copyright © 2020 Aleksandra Bitenc-Jasiejko et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Introduction. Lower back pain (LBP) is almost a problem of civilizations. Quite often, it is a consequence of many years of
disturbed distribution of tension within the human body caused by local conditions (injuries, hernias, stenoses, spondylo-
listhesis, cancer, etc.), global factors (postural defects, structural integration disorders, lifestyle, type of activity, etc.), or
systemic diseases (connective tissue, inflammation, tumours, abdominal aneurysm, and kidney diseases, including urolithiasis,
endometriosis, and prostatitis). Therefore, LBP rehabilitation requires the use of integrated therapeutic methods, combining
the competences of interdisciplinary teams, both in the process of diagnosis and treatment. Aim of the Study. Given the above,
the authors of the article conducted meta-analysis of the literature in terms of integrated therapeutic methods, indicating the
techniques focused on a holistic approach to the patient. The aim of the article is to provide the reader with comprehensive
knowledge about treating LBP using noninterventional methods. Material and Methods. An extensive search for the materials
was conducted online using PubMed, the Cochrane database, and Embase. The most common noninterventional methods have
been described, as well as the most relevantly updated and previously referenced treatment of LBP. The authors also proposed
noninvasive (measurable) diagnostic procedures for the functional assessment of the musculoskeletal system, including initial,
systematic, and cross-sectional control. All figures and images have been prepared by the authors and are their property.
Results. This review article goes beyond combining a detailed description of each procedure with full references, as well as a
comprehensive discussion of this very complex and troublesome problem. Conclusions. Lower back pain is a serious health
problem, and this review article will help educate physicians and physiotherapists dealing with LBP in the options of evidence-
based treatment. Ultimately, the article introduces and postulates the need to systematize therapeutic procedures in LBP
therapy, with a long-term perspective.

1. Introduction 20% of the global population; 24–80% of patients have a

relapse of pain in the first year [2–5]. Despite the fact that
Lower back pain of mechanical origin is caused by injuries 31% of patients with LBP demonstrate an improvement
and/or degenerative conditions of the vertebrae and inter- within 6 months, the recurrence of moderate pain is re-
vertebral discs and by the faulty distribution of forces within ported in 33% of cases, and acute pain is observed in 15% of
the soft tissues. The most frequently diagnosed mechanical sufferers within 1-2 years [6–8]. Recent studies indicate that
problems are disc herniation (including disc fractures and people with LBP experience pain and the related disability
their dehydration), compression fatigue fractures, and acute longer than patients suffering from pain in the course of
traumatic injuries [1]. In its chronic form, LBP affects over other diseases [9–11]. Nonspecific back pain is increasingly
 2 Pain Research and Management

affecting young people, and this can be an important de- increased tension, fascia densification and tensegration
terminant of LBP in adulthood [12–15]. The necessity of disorders, and so on, are the primary causes of discopathy
systematization of therapeutic procedures results from the and degenerative conditions of the spine [1, 3, 44, 45].
fact that back pain causes motor disability, thereby signif- This approach forces MT specialists to plan therapeutic
icantly reducing (and even temporarily disabling) motor procedures in a systematic way, starting from actions aimed
activity with the consequent absence from work, particularly at eliminating acute pain and ending with structural inte-
in the countries with a highly developed market economy gration, reduction of abnormal compression forces, and
[1, 16–18]. It has also been found that LBP, caused, for consequently stabilization. Given that the therapeutic pro-
example, by discopathy, recurs after surgery [19–21]. LBP is cedure (especially in the case of chronic pain) can be ex-
a problem of civilizations, with epidemiological data clearly tended and periodic exacerbations are possible, in addition
indicating the growth of the population affected by the to imaging examinations, regular objectified monitoring of
condition. Therefore, it is important to take systematic ac- the patient’s condition is necessary, the more so because
tions in two areas: there is also a literature discrepancy as to the use of imaging
examinations [46–49]. According to guidelines, imaging
(i) Differentiation of the problem, which should include
diagnostics is not recommended in the following cases:
both initial diagnosis and regular monitoring
(ii) Systematizing nonsurgical and nonpharmacological (i) Pain lasting less than six weeks: no red flags, the
therapeutic procedures, with particular emphasis on patient with LBP not having neurological symptoms
the roles played by interdisciplinary teams (pain or numbness of the lower limbs, sciatica, and so
on), and osteomyelitis is not suspected
Given the different aetiologies of LBP and severe pain,
interdisciplinary teams, including doctors (imaging diag- Red flags include trauma, sudden weight loss, cancer, the
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nostics and pharmacotherapy), physiotherapists, specialists long-term use of steroid drugs, increasing neurological
in psychosomatic diseases (therapy of anxiety syndromes symptoms, urinary incontinence, age over 70, and osteo-
accompanied by chronic pain), dieticians (lifestyle, main- porosis. A prolonged treatment lasting over 12 months is
tenance of normal body weight, and elimination of visceral also a red flag [3, 50, 51]. Given the huge role of conservative
problems, including intolerance, intoxication, and the therapy in LBP, the procedures used in the treatment of red
presence of parasites), should be involved in the therapeutic flags should take into account the role of extended medical
process of back pain syndrome [22–29]. Scientific and re- history taken by manual therapy specialists, educators,
search literature demonstrates, however, that evidence for physiotherapists, etc. [52].
multidisciplinary rehabilitation is rare, and physical and However, an imaging examination is the most important
behavioural procedures are limited [30]. The impact of and objective diagnostic method to differentiate the problem
biopsychosocial factors on LBP, compared to biomechanical of back pain of the spinal origin. Magnetic resonance im-
influences, is an important developmental aspect in research aging (MRI) is applied to assess the origin of neurological
and scientific work [31]. Biological treatment is also in an and soft tissue pain, while X-ray (X-ray/RTG) is used to
experimental phase [32, 33]. evaluate posttraumatic bone and joint changes as well as
The results of scientific and research studies are con- abnormalities in the structure of the bones and their ar-
sistent in the conclusion that nonsteroidal anti-inflamma- rangement. Unfortunately, due to invasiveness and eco-
tory drugs combined with muscle relaxants are effective nomic aspects, imaging examinations cannot be used to
methods of treating LBP [34–37]. Most literature sources monitor the therapy. They are also not applicable in func-
indicate that staying in the reclined position has no effect on tional therapy and re-education of movement patterns,
acute pain [38–43]. It has been repeatedly noted that the motor activity, etc.
following factors play a role in the prevention of acute pain A primary therapeutic task in LBP is to educate the
with mild aetiology: patient on pain management. In addition to education on
rest and physical activity, neurophysiological education is
(i) Education of people with LBP in methods to avoid very important. This is a cognitive-behavioural interven-
overloading tion to provide knowledge of neurophysiology and neu-
(ii) Moderate physical activity, using decompression roscience of pain in order to change beliefs about illness,
movements in a position without pain or a signif- disability, and above all adaptation to pain [53–55]. The
icantly reduced pain, relaxing and stabilizing management should differentiate the origin of pain, both in
structures terms of mechanical (motor) stimulus and the protective
(iii) Return to normal activity [34, 35, 37, 39] (nociceptive) mechanism [56–60]. A literature study in-
dicates a significant interaction between treatment con-
However, given the fact that, in most cases (i.e., 70% of ditions and the intensity of LBP, and thus physical fitness.
people with LBP) complaints are caused by the dysfunction Educational activities should be conducted in a clear and
of myofascial structures, the most important scientific re- concise manner, adjusted to the intelligence, education,
search issue should be the systematization of manual therapy and expectations of patients. Particular emphasis should be
(MT) procedures. The more so (apart from trauma, fatigue put on the ability of patients to act independently in case of
fractures, postural defects, and systemic diseases) in faulty exacerbations. The family also plays an important role in
force migration, arising from functional structure shortcuts, the treatment [61–63].
 Pain Research and Management 3

1.1. Purpose of Meta-Analysis. The aim of the study is to techniques to improve the functionality of the musculo-
review the literature on integrated therapeutic techniques skeletal structures and the entire body (structural and organ
used to treat LBP as well as to indicate the methods of integration). Holistic therapy is based on, among other
postural and functional diagnostics and to provide the things, manipulation (OMT), including spine manipulation,
reader with comprehensive knowledge of the treatment of muscle energy techniques (MET), visceral techniques, and
LBP using noninterventional methods. exercises [81, 82]. It has been shown that OMT has a
clinically significant effect on reducing pain and improving
2. Methodology of Meta-Analysis the functionality of the spine, lower limbs, and pelvis, both in
patients with acute and chronic nonspecific LBP (including
The literature reviewed in this study covers the period of 21 pregnant and postpartum women) [38].
years (1998–2019). The extensive search for materials was Muscle energy technique (MET): muscle energy tech-
conducted online using PubMed, the Cochrane database, niques have several applications. They can be used to
and Embase. The results were evaluated and checked for lengthen the shortened muscle, strengthen the weakened
correct qualification, indicating and confirming the im- muscle, and reduce local swelling and passive congestion.
portance of combining different therapeutic methods of LBP The technique is usually applied as part of a therapeutic
and the relevance of interdisciplinary teams to be included in complex used in acute LBP [83–85]. It also brings good
the LBP diagnosis and rehabilitation. The analysis covered results in hypomobility of the sacroiliac joints which affects
175 articles selected from a group of 1363 publications. All LBP patients [86, 87].
figures and images have been prepared by the authors and High velocity low amplitude (HVLA) is a technique of
are their property. short-lever manipulation of the joints that acts subtly and
precisely. The method is based on unblocking the joint by
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3. The Merits of the Issue applying a low amplitude and high velocity force. Previous
reports provided little significant evidence that spine ma-
3.1. Manual Therapy in LBP. Various therapeutic methods nipulation was better than other treatments for chronic low
are used in the management of patients with LBP. However, back pain [88, 89]. However, recent reviews suggest that
we should pay attention to the procedures treating the spine manipulation is an option of pain management,
functionality of the musculoskeletal system in a holistic way. though its effectiveness may vary depending on the duration
The therapy based on structural integration is called ten- of symptoms and the method of treatment [90, 91]. In the
segration. A role of the deep fascia in the aetiology of LBP following example, manipulative and osteopathic techniques
was already indicated in 1939 [64]; modern medicine seeks (HVLA) were combined with the SNAG techniques
one of the main causes of nontraumatic back pain in this according to Mulligan’s concept. This was done to improve
structure [65–69]. Excessive tension of the tissues creates a the glide of the joints with the muscle function, and this
damaging stimulus that is distributed within the human distinguishes Mulligan’s concept from other manipulative
body in a linear manner [69–71]. Hence, pain may appear in methods.
a place distant from the site where the pain stimulus AKA-H (Arthrokinematic Approach-Hakata) method of
originally occurred [68, 72–75]. This indicates that the manual therapy, developed by Setsuo Hakata in 1979, is used
restoration of tension in anatomical tapes is essential for the to treat abnormalities in joint movement. Scientific literature
process of rehabilitation, pain therapy, and restoring indicates that the effectiveness of the AKA-H method has
structural balance. As a result, greater strength is generated, been proven, both in the case of acute low back pain (as S.
and loads are transferred with the consequent shock ab- Hakata did), joint contractures, neuromuscular retraining,
sorption and the ability to support the muscles stabilizing as well as in the case of chronic pain. The AKA-H method
the spine, which are closely connected with a given fascia primarily includes techniques of neuromobilization and
tape [68, 76]. joint mobilization, including two procedures: manual
The concept of fascial tapes allows the connections be- therapy and physical therapy [92–98].
tween the myofascial lines causing dysfunction of the body Mulligan’s concept is another method complementing
posture to be determined, thereby including them in ther- the therapy of LBP. SNAG (sustained natural apophyseal
apeutic procedures. This has a huge impact on the effec- glide) is one of the most important MWM techniques. It
tiveness of the therapy. The holistic approach to the fascial involves the use of a passive glide on the vertebra and active
system is based on the current scientific research on fascial movement made by the patient. The glide occurs in the
anatomy. A review of literature in this area clearly reveals articular plane, and the movement is performed in loading
that few authors treat fascia as a three-dimensional system [99]. The reports indicate that the addition of the SNAG
[76–78]. Nevertheless, it has been repeatedly pointed out technique to other rehabilitation methods improves the
that manual therapy based on the concept of tensegration range of spinal mobility and reduces pain [100–102]. The
(structural integration) is one of the most effective methods literature also indicates that compared to incorrect mobi-
of balancing tensions within the motor organ in LBP therapy lization, the SNAG technique did not bring better results in
[79, 80]. terms of mobility [99]. According to the authors, no
Osteopathic techniques: osteopathic manipulative comment can be made on the results of this study because
treatment (OMT), used in patients with LBP, are integrated the technique was performed in asymptomatic patients.
therapeutic methods taking into account various manual Konstantinou et al. demonstrated that MWM therapy
 4 Pain Research and Management

significantly increased the average range of spinal motion compared to local stabilization training of the lumbar spine
compared to patients with LBP receiving a placebo [103]. [127].
Therapy of patients with LBP often requires the use of Yoga is a therapeutic method that conceptually combines
neuromobilization which is largely overlooked in various psychoemotional and structural balance. It is a collection of
MT methods. many positions that supplement the therapy (stabilization)
Neuromobilization allows nerve shifting in relation to the in LBP patients with both acute and chronic pain in a very
structures surrounding the neuronal tissue to be restored. It positive way [128–130]. It also has a positive effect on re-
brings back the possibilities of stretching and tightening of spiratory functions and consequently a direct impact on the
the nerves. The technique should be used as early as possible stability of the spine [131, 132].
when there are no irreversible morphological changes; it
should cover all tissues affected by the pathology [104, 105].
3.4. Stabilization of the Patient’s Condition and Stabilization
Exercises. In recent years, the stability of the trunk (spinal
3.2. Other Methods Used in LBP Therapy. Acupuncture is a cord) has been defined as the ability to maintain a stable
nonspecific therapy having a large spectrum of indications. neutral position of the spine. The global muscles participate
It activates central brain pathways, thus inhibiting pain in movements of the torso, while local muscles play an
reactions [106]. Research and scientific literature studies important stabilizing role. Stabilization training in patients
indicate the effectiveness of acupuncture in improving the with LBP reduces pain and instability as well as preventing
function and relieving pain in LBP patients, but the results relapses [133–135]. Hides et al. described how cricket players
vary individually [107]. A review of studies gives no con- suffering from LBP were subjected to stability training
clusive evidence that acupuncture is more effective in the (multifidus, transverse abdominal and pelvic floor muscles)
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treatment of chronic pain than a placebo or sham acu- with the consequent decrease in pain [136]. According to the
puncture [108–111]. The evidence for acupuncture effec- literature, an ultrasound observation detected no advantage
tiveness in LBP also remains controversial [112]. On the one of stabilization exercises over general exercises [137]. There
hand, unambiguous points (meridians) relating to LBP were is also an opposing conclusion that stabilization exercises are
determined, and the number of people taking advantage of more effective than standard training [138]. However, we
acupuncture has increased significantly in recent years must remember that the therapy aimed at unblocking the
[113–115]. On the other hand, similar to assessing the ef- joints by correcting the muscle tension is complex. Searching
fectiveness of manual therapy, there are controversies over for the best exercises, focused on TrA (transversus
the methodology of scientific works, unjustified comparison abdomnis) and MF (multifidus), should be done under
of the study population [116, 117]. ultrasound guidance. This is due to the fact that the correct
Kinesio Taping (KT) is a relatively new method, sup- contraction is a key to individual and personalized stabili-
porting the treatment of musculoskeletal disorders, in- zation training, where proper mobility of the joints is re-
cluding LBP. KT is not only sensory but also a quired. It is easy to monitor therapeutic progress in this
proprioreceptive interaction. An appropriate application, regard by measuring the thickness of a given muscle in an
adjusted to the patient’s needs, allows the regeneration of the ultrasound, as indicated in the literature [139–141]. In
places affected by the disease and improves microcirculation. special cases, an ultrasound can be used to evaluate the
Moreover, the method has a positive effect on the nor- progress of therapy.
malization of the fascial system tension and a reduction of Even though the costs of magnetic resonance imaging,
pressure on pain receptors. This results in folding the skin surgery, and corticosteroids have increased significantly, no
surface and increasing the space between the skin and fascia improvement has been observed in the incidence of LBP and
[118, 119]. The method improves blood and lymph mi- the consequent disability [48, 142]. Each LBP assessment
crocirculation and activates self-healing processes. The lit- procedure should begin with the taking of a detailed medical
erature indicates that the use of KT reduces pain and history and performing a physical examination, including
instability of the spine [120–122]. identification of red flags. An MRI is one of the most useful
diagnostic tools to evaluate the condition of the interver-
tebral discs that have a significant effect on kinematic
3.3. Rehabilitation Exercises and Autotherapy. The scientific patterns [143].
literature describes many exercise methods used to reduce The physical examinations are used mainly to assess red
and prevent LBP [123, 124]. They are applicable both in flags, the quality of pain, and neurological symptoms and to
acute pain, in autotherapy, and in stabilization of the perform visual evaluation of the quality of movement [144].
musculoskeletal system. Given the relationship between functional disorders and
The McKenzie method is designed to reduce the intensity nonspecific back pain, the authors believe in the importance
of acute and chronic pain of the lower back and belongs to of diagnostic procedures to evaluate the quality of move-
treatment systems focused on maintaining proper posture ment and in the need to conduct scientific and research
and consists of the repetition of the same movements. The works in this area. Particularly, in the era of time-space
McKenzie protocol is one of the most common recognized research technologies, procedures should be focused on the
physiotherapeutic concepts used in patients with LBP implementation of measurable, objective, noninvasive, and
[125, 126]. However, this method proved to be less effective economic rehabilitation methods [145–147].
 Pain Research and Management 5

(a) (b)
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Figure 1: MRI. Date of examination: (a) 4 December 2018 and (b) 20th September 2019.
th

Figure 2: A photogrammetric examination performed using the BIOMECH Studio software.

3.5. Evidence for the Considerations above. A reference to pressure on the meningeal sac. According to the classifi-
postural and functional diagnostics and integrated thera- cation, the modic changes can be defined as type I, which is
peutic procedures on the example of a 28-year-old patient an important positive prognostic factor justifying the use of
who has suffered from pain since the age of 15. The medical noninvasive therapeutic methods. However, at the same
history revealed that such an intensive acute LBP did not time, scientific literature indicates that, in the old age, there
appear until the last two weeks. A magnetic resonance is a high risk of transformation of a type-I modic change into
imaging visualized class IV changes in the intervertebral a type-II modic change [149, 150]. The incidence of LBP in
discs (Figures 1(a) and 1(b)) (according to the classification modal changes ranges from 18% to 62% [151, 152]. Type II
by Pfirrmann et al.) [148] in L3/L4 (protrusion) and L4/L5 modic changes are the most common in segments L4/L5 and
(extrusion) (Figures 1(a) and 1(b)). After therapy lasting L5/S1, and disk degeneration is an important risk factor
more than 8 months both results should be qualified as a [125, 153, 154]. The condition of the disc is influenced by the
protrusion, without migration into the spinal canal or supply of nutrients to the cartilaginous endplate that may be
 6 Pain Research and Management
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(a) (b)

Figure 3: The exemplary result of the range of motion in the lumbar part, flexion/extension, lateral flexion to the left/right, and rotation to
the left/right: the result (a) before a therapeutic session and (b) after a therapeutic session.

Table 1: The report generated before and after a therapeutic session.

Movement Result before a therapeutic session Result after a therapeutic session
Spinal flexion of the lumbar part 75.0 102.5
Spine extension of the lumbar part 8.0 24.2
Lateral bend of the spine to the left 23.7 21.8
Lateral bend of the spine to the right 26 23.7
Spinal rotation to the left in the lumbar part 19.7 31.1
Spinal rotation to the right in the lumbar part 11.6 36.9
Abduction in the left hip joint 27.8 41.5
Adduction in the left hip joint 26.7 26.5
Abduction in the right hip joint 27.9 35.2
Adduction in the right hip joint 24.5 25.3
Flexion in the left hip 79 96.9
Flexion in the right hip 81.3 103.6
Internal rotation in the left hip joint 25.7 25.1
External rotation in the left hip joint 46.9 59.5
Internal rotation in the right hip joint 27.4 39
External rotation in the right hip joint 45.8 54
Extension in the left hip joint 21.2 29.5
Extension in the right hip joint 15.4 29.5

disturbed by biomechanical abnormalities in the lumbar of the disc itself, postural parameters and functionality of the
region [153]. musculoskeletal system are important diagnostic aspects.
Given that the condition of the intervertebral discs is also The initial evaluation and systematic monitoring of the
influenced by spine kinematics, in addition to the evaluation patient were supplemented with computer diagnostic
 Pain Research and Management 7
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(a) (b)

Figure 4: The exemplary result of pelvic parameters during standing and pelvic kinematics. The examination was performed at a therapeutic
session: the result (a) before a therapeutic session and (b) after a therapeutic session.

(a) (b)

Figure 5: The exemplary result of a gait examination (a) before and (b) after a therapeutic session.

methods using the BIOMECH Studio program applied at patient lying on the side (this position was chosen for the
each therapeutic visit. This aspect is relevant to the func- examination because lying on the back caused pain). In the
tional assessment, making examination results objective and first stage of the therapy, the use of osteopathic craniosacral
measurable. The technique is also used to monitor the therapy was impossible due to pain in the position suitable
progress of rehabilitation procedures. for manipulation and intense pain-related anxiety. Instead,
The first stage of the therapeutic process using manual functional mobilization of structures was performed
therapy (MT) was pain relief. For this purpose, the tech- according to Mulligan, which gradually eliminated pain and
niques were applied to restore tension in individual ana- increased the range of motion in the lumbar region (the
tomical chains (according to the concept of Anatomy examinations performed in painless positions or until pain
Trains). The aim of the therapy was to integrate tensions occurred). Manual therapy also included neuromobilization.
within the myofascial structures in order to restore body After each visit, the patient had breathing training (auto-
balance and, as a consequence, corrective and stabilizing therapy) carried out at home and at work. Kinesio Taping
forces. At the same time, respiratory education and isolation was also applied after the therapy (the type of application
of tonic deep muscle contraction were carried out with the was chosen depending on the patient’s needs). This stage
 8 Pain Research and Management

(a) (b)

Figure 6: The exemplary result of a balance (stabilometric) examination performed at a therapeutic session.
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(a) (b)

Figure 7: The exemplary result of the postural assessment of pressure distribution, in lateral and antero-posterior view measured (a) before
and (b) after a therapeutic session.

lasted three months, and there were exacerbations of pain increasing the range of motion in the hip joints. Mulligan
caused by the lack of the patient’s compliance to perform mobilization was carried out throughout the entire stages I
exercises regularly and due to the intensification of pro- and II. The patient mastered deep muscle coordination with
fessional activities. maintained respiration while standing. Autotherapy was
The second stage of the therapy was carried out in the enriched with education of the patient on the exercises using
absence of pain or/and its full control. The stage was focused limbs. Their goal was to integrate the superficial muscles
on increasing mobility in the sacroiliac joints and facet joints with cocontraction of the deep muscles. Kinesio Taping was
of the spine. The HVLA osteopathic technique was used to also applied in order to maintain the effects of therapy. This
precisely operate on the short lever and, consequently, avoid stage lasted three months.
the need to involve other joints. At the same time, MET The third stage of the therapy consisted of postural and
procedures were implemented, activating the work of the hip dynamic muscle training. The examination of the posture
rotators. It was aimed at stabilizing the sacroiliac joints and revealed numerous disorders, including pelvic drooping on
 Pain Research and Management 9

(a) (b)

Figure 8: The exemplary result of assessing the mutual relationship between the feet and the proportions of the feet.
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(a) (b)

Figure 9: The exemplary result of the foot arch examination (a) before and (b) after a therapeutic session (the examination is performed
while standing).

one side, anterior tilt of the pelvis, functional knee and foot elements allowed for shock absorption in each phase of the
valgity, and first degree of longitudinal flat feet and trans- gait.
verse flat feet. Stabilization exercises have been enriched with The patient attended therapeutic visits for 8 months,
training on unstable ground. with a frequency of once a week and a duration of 45
After this stage, the patient performed exercises aimed minutes. Diagnostic procedures were implemented at every
at learning the correct (ergonomic) gait pattern and relief stage of the therapy (at each visit). They included photo-
positions (decompression). She also received orthopaedic grammetric and videogrammetric methods implemented
insoles designed especially for her needs, to eliminate during the pedobarographic assessment performed while
structural changes in the feet and knees and helping to standing and walking (duration of static analysis was 20
maintain the correct gait pattern. The personalized or- seconds, and gait examination lasted for about 1–1.5 min-
thopaedic insoles supported subsequent phases of gait, utes). The examination of the range of motion and pelvic
taking into account the patient’s mobility; dynamic kinematics evaluation lasted approximately 3–5 min. The
 10 Pain Research and Management

(a) (b)

Figure 10: The exemplary result of the foot arch examination (AI index) (a) before and (b) after a therapeutic session (the examination is
performed while walking).
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(a) (b)

Figure 11: The exemplary graph presenting the results of strength distribution and time-space parameters during walking, measured at a
therapeutic session.

functionality examinations proposed by the authors are can be observed on the TV screen while performing exercises
noninvasive and economical (inexpensive). (Figure 3).
Procedure I: photogrammetry and videogrammetry for Before and after each therapy, diagnostic procedures
anthropometry and physical examination (Figure 2). were implemented to assess the range of motion of the spine
Procedure II: the examination of the range of motion in and hip joints. They allowed for the evaluation of the
®
the joints using the WIVA Science sensory-motor sensor.
The examination was used to evaluate the functionality of
therapeutic process and effectiveness of the therapeutic
method (i.e., maintaining the effects of therapy during a
structures as well as to regularly monitor the effectiveness of week break between each visit). An exemplary report is
therapeutic methods. A user-friendly interface of the BIO- presented in Table 1.
MECH Studio software is also an important psychoemo- The evaluation of pelvic kinematics and gait was also
tional aspect for the patient, as the progress of the therapy
®
carried out using the Wiva Science sensory-motor sensor.
 Pain Research and Management 11

(a) (b)

Figure 12: The exemplary result of the assessment of foot progression, carried out (a) before and (b) after a therapeutic session.
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Pelvic mobility plays a pivotal role in maintaining balance of orthopaedics, traumatology, rehabilitation of the musculo-
the neuromuscular system [155]. It is closely correlated with skeletal system, and in the assessment of functional disorders
the quality of gait, mainly space-time parameters, which has in spinal overload diseases. A pedobarographic examination
been repeatedly demonstrated in physiological [156–158] also allows for the postural evaluation in the context of
and pathological gait [159–162]. The examination using the structural integration, i.e., testing the distribution of pres-
sensor allowed for the observation of the pelvis during sure on the right and left side and in an antero-posterior
walking and standing (including pelvic tilt angle) as well as view. In patients with LBP, especially in the phase of pain, we
for the analysis of pelvic movements in the three planes: observe compensatory disorders, causing the centre of
anterior/posterior tilt, falling and lifting of the iliac alae, and gravity to be shifted to one limb, which in chronic conditions
rotation (Figures 4(a) and 4(b)). leads to postural overload disorders. The exemplary result of
The examination of the angle of lumbar lordosis under the general analysis of pressure distribution in the patient’s
static and dynamic conditions is of great importance, mainly body is presented in Figures 7(a) and 7(b) (the result ob-
due to the close correlation between LBP and abnormalities tained before and after a therapeutic session).
of lumbar lordosis [163]. Pedobarography also allows for the assessment of the
The exemplary results of gait analysis before and after mutual relationship between the feet, angles of foot ab-
therapy are shown in Figures 5(a) and 5(b). duction, and proportions, which is presented in Figures 8(a)
The examination of postural functionality parameters and 8(b). In the practice of the functional and postural
can also be carried out using pedobarography, which allows assessment, the result should (and can) be correlated with
for the static and dynamic examination from a perspective of the outcomes of hip joint mobility and the position of the
the feet. The relationship between the function of the feet lower extremities in the transverse plane. In line with the
and LBP has been repeatedly indicated in the scientific and assumptions of structural integration, the result correlates
research literature [164]. A pedobarographic examination, with the position of the pelvis and lumbar lordosis.
which is a diagnostic method for the evaluation of balance A pedobarographic examination can also be used to
(static test), is widely used in the assessment of the functional evaluate the foot arch, both while standing (Figures 9(a) and
stability of the musculoskeletal system, particularly the 9(b)) and walking (Figures 10(a) and 10(b)).
body’s ability to carry loads (static structural integration) The condition of the foot arch is of key importance to
and compensation (Figure 6) [165–169]. Stabilometry is an shock absorption during locomotion. The foot arch is the key
important aspect of functional diagnostics of the muscu- to shock absorption during locomotion. A pedobarographic
loskeletal system, and its inclusion in one device (i.e., in a examination also allows for the observation of forces and
pedobarograph) significantly reduces the cost of biome- time-space parameters during locomotion (Figures 11(a)
chanical diagnostics [170–177]. and 11(b)).
Pedobarography also allows for the registration of the An important issue is also the function of changing the
values of unit pressure, gait determinants, and distribution position from standing on the foot to standing on the toes
of pressure on the feet, making it applicable in the activities (Figures 12(a) and 12(b)) which closely correlates with the
aimed at the early detection of postural threats [178]. Hence, mobility in the hips during walking and running, mainly due
the wide application of pedobarography includes to supination and pronation of the foot.
 12 Pain Research and Management

4. Conclusions years lived with disability for 310 diseases and injuries,
1990–2015: a systematic analysis for the Global Burden of
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“Lives on hold,” The Clinical Journal of Pain, vol. 29, no. 10,
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